The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on November 27, 2000, at the request of a worker advisor, acting on behalf of the claimant. The Panel discussed this appeal on several occasions, the last one being May 7, 2001.

Issue

Whether or not responsibility should be accepted for the proposed carpal tunnel decompression surgery including any associated time loss, treatment or medical expenses.

Decision

That responsibility should not be accepted for the proposed carpal tunnel decompression surgery including any associated time loss, treatment or medical expenses.

Background

In June 1999 the claimant submitted a claim for compensation benefits indicating that her employment activities as a hairstylist caused sharp pains, numbness and weakness in both hands and wrists. The diagnosis reported by the attending physician on April 7, 1999, was questionable carpal tunnel versus tendonitis.

The claim for compensation was initially rejected by primary adjudication, however, Review Office overturned the decision on December 3, 1999. Review Office

accepted the claim on an aggravation basis but did not conclude that the claimant's employment was causative for carpal tunnel syndrome (CTS). According to Review Office, any surgery proposed in the future would not be the WCB's responsibility.

Subsequent to Review Office's decision, medical information was submitted from a specialist dated January 31, 2000. The specialist noted that recent nerve conduction studies were negative for CTS. Examination findings were as follows: "both hands appeared normal. The Tinel's sign is negative. However, the Phalen's test is positive after 5 seconds bilaterally. No other abnormalities are detected." The diagnosis rendered was "bilateral carpal tunnel syndrome." The specialist commented that surgical decompression would benefit the claimant since splinting had not helped her. The request for carpal tunnel decompression surgery was denied by primary adjudication based on Review Office's decision, i.e. that the claimant's employment was not causative for CTS. The claimant appealed this decision to Review Office.

Following consultation with a WCB medical advisor on May 2, 2000, Review Office determined that no responsibility would be accepted for the proposed carpal tunnel decompression surgery. In reaching this decision, Review Office noted that the present findings were extremely limited and given the negative nature of the nerve conduction studies, there was no reason to alter its previous decision to deny responsibility for the proposed surgical procedure. Review Office also looked into the claimant's entitlement under policy 44.10.20.10, which governed the adjudication of pre-existing conditions. Review Office considered that the workplace injury no longer played a material role in the claimant's ongoing symptomatology beyond October 19, 1999 given the claimant's time away from employment.

On June 14, 2000, a worker advisor submitted a June 1, 2000, report from a hand specialist for consideration by Review Office. The specialist was of the opinion that the claimant had evidence of CTS, confirmed by her medical history and diagnostic tests. The specialist related the claimant's CTS to the repetitive hand activities required in her occupation as a hairdresser. The worker advisor did not concur with Review Office that the claimant had any pre-existing condition.

On June 30, 2000, Review Office confirmed its earlier decision of May 2, 2000 and also determined that no responsibility should be accepted for the proposed carpal tunnel decompression surgery. Review Office stated that there was no new medical documentation to substantiate the acceptance of the proposed carpal tunnel decompression surgery as a responsibility of the WCB. On August 25, 2000, the worker advisor appealed Review Office's decision and an oral hearing was requested. The worker advisor submitted to the Appeal Panel a September 11, 2000 report from the hand specialist as well as medical literature concerning carpal tunnel syndrome.

On November 7, 2000, an Appeal Panel hearing was held. Following discussion of the case, the Panel requested that additional medical information be obtained from the claimant's treating orthopaedic surgeon. On February 1, 2001, all concerned parties were provided with a copy of the orthopaedic surgeon's response dated January 17, 20001 and were asked to provide comment.

On February 19, 2001, the Panel met again to discuss the case and decided that additional information should be obtained from the physiotherapy clinic where the claimant attended for treatment in August 1999. A response from the physiotherapy clinic dated April 20, 2001, was later received and provided to the interested parties for comment. On May 7, 2001, the Panel met to render its final decision with respect to the issue under appeal.

Reasons

The WCB initially accepted this claim on the basis the claimant "may have incurred a tendonitis condition that had been aggravated by her work." The treating physician confirmed to the WCB by letter dated September 1, 1999 that in his opinion the claimant "has bilateral wrist and forearm volar pain consistent with a tenosynovitis." In a September 21st, 1999 memorandum, a WCB medical advisor, following a review of the file, concurred with the view that repetitive ongoing flexion movements of the fingers and wrist could possibly give rise to a "tenosynovitis of the flexor group of tendons."

A second WCB medical advisor examined the claimant on October 19th, 1999. His suggestions and recommendations were as follows: "This is not clearly a carpal tunnel syndrome. She has negative Phalen's and Tinel's signs. While she may have complaints historically of what sounded like a tendonitis involving her forearms and wrists, this is not borne out on today's examination. There is no swelling, nor increase in temperature. There is no evidence of a de Quervain's tenosynovitis." This same medical advisor subsequently clarified his foregoing opinion on December 2nd, 1999.

"To reiterate my exam notes, I think that historically one can accept what may have been a tendinitis. However, there is no current evidence of same at time of my examination. As she has been off work for a prolonged period of time with still ongoing complaints there is less likelihood of relationship to work as causative factor. Her work could possibly irritate an underlying condition. (Aggravation now resolved.)"

The claimant underwent a course of physiotherapy at a local clinic as part of her treatment regimen. She was initially assessed on August 16th, 1999 and these were a few of the clinical findings: "Pain in lateral elbow regions radiating into the forearms bilaterally; Decreased active hand and wrist movements bilaterally, but full range passively; Tenderness to palpation at the common extensor tendon insertions at the lateral epicondyle bilaterally." We are of the view that these findings are consistent with a diagnosis of bilateral lateral epicondylitis. Physiotherapy treatment administered to the claimant comprised of ice to lateral elbow regions bilaterally, ultrasound, acupuncture and soft tissue massage with frictions at the lateral epicondyles bilaterally.

A neurologist examined the claimant on April 29th, 1999. He reported that the claimant's swelling of the wrist showed some improvement after she stopped working as a hairdresser. In his opinion, "It was felt that, whereas, the greater part of her symptoms were swelling and pain in the wrists, suggesting a localized arthropathy plus probably tendinitis probably associated with her work". Nerve conduction studies carried out on July 19, 1999 revealed "normal median nerve conductions bilaterally".

We find based on the weight of evidence that the claimant's carpal tunnel syndrome decompression surgery was not, on a balance of probabilities, a consequence of her work duties as a hairdresser. The clinical testings as well as the nerve conduction studies were marginal at best for confirming a carpal tunnel syndrome condition. Accordingly, the WCB should not accept responsibility for the decompression surgery including any associated time loss, treatment or medical expenses. The claimant's appeal is hereby dismissed.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
L. Butler, Commissioner

Recording Secretary, B. Miller

R. W. MacNeil - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 30th day of May, 2001